Provider Demographics
NPI:1194391441
Name:SMITH, SHARON DESIREE (CNA)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:DESIREE
Last Name:SMITH
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:735 FULTON AVE
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29303-2841
Mailing Address - Country:US
Mailing Address - Phone:864-564-7534
Mailing Address - Fax:
Practice Address - Street 1:400 S CONVERSE ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29306-3520
Practice Address - Country:US
Practice Address - Phone:864-310-3598
Practice Address - Fax:864-428-1213
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-27
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC557052374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty